Recognizing Obstructive Sleep Apnea in Patients With Traumatic Brain Injury

Christopher J. Lettieri, MD


November 11, 2013

Impact of OSA on Outcomes

Impaired sleep can have an adverse impact on cognition, attention, and judgment. Among patients with TBI, the presence of sleep complaints portents worse outcomes, is associated with diminished quality-of-life measures, and has been shown to impair rehabilitation efforts and progression.

Failure to recognize sleep disorders in TBI may adversely affect recovery. Wilde and colleagues[13] assessed the impact of sleep disturbances on cognition in a clinical trial comparing 19 patients who had TBI and OSA with 16 patients who had only TBI. The 2 groups were similar in age, education, presenting Glasgow Coma Scale score, and time since injury. Patients with TBI and OSA performed worse on measures of verbal and visual delayed recall, and comparably on motor, visual construction, and attention tasks. Researchers also found more lapses in attention in those with both conditions. The authors concluded that TBI coupled with OSA is associated with significant impairments of sustained attention and memory compared with patients who have TBI alone.

Castriotta and colleagues[11] evaluated the impact of therapy for sleep disorders in 57 patients at least 3 months after a TBI. Of the cohort, 23% had OSA. The authors found that although continuous positive airway pressure effectively ablated obstructive events, it did not lead to improvement in objective measures of sleepiness. Similar to other reports, TBI patients may have additional causes of persistent sleepiness, in particular a centrally mediated posttraumatic hypersomnia syndrome.


TBI is a growing societal concern that is increasingly recognized among athletes, elderly persons, and military personnel. These injuries encompass multifaceted disease processes and are commonly associated with psychiatric conditions (depression, PTSD, and anxiety), neuromuscular and neurocognitive impairments (chronic pain, physical rehabilitation, and impaired cognition), and sleep-related disorders (sleep apnea, posttraumatic hypersomnia, periodic limb movement disorder, insomnia, and circadian rhythm sleep disturbances). Sleep disorders in patients with TBI are often underdiagnosed and undertreated.

There is increasing recognition that sleep disruption can complicate TBI, and unrecognized or untreated sleep disorders can worsen outcomes, increase disability, or impair rehabilitation. Although sleep complaints are nearly universal among persons who have had a TBI, it appears that the mechanism of injury may play a role in the development of specific sleep disorders. Given the extremely high prevalence of sleep complaints, patients with TBI should be evaluated for sleep disorders or referred for formal sleep evaluations, because recognizing and treating these conditions may improve outcomes.

Because of the inherent cognitive limitations in TBI patients as reporters of their symptoms, all TBI patients with suspected sleep disturbances should undergo a comprehensive, objective evaluation, especially given the established adverse impact of sleep disruption on cognition in this already impaired population.


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